Presentation Transcript

1. Building Public-Private Partnership for Health System Strengthening Working with the Private Sector to Control Tuberculosis April Harding The World Bank Bali Hyatt Hotel, Sanur, Bali 21-25 June 2010
2. Site of Treatment– South Southeast Asia
3. Why TB patients go private Patient perceptions & preferences (e.g. convenience, stigma, gender). Inconvenient opening hours & long waiting times Provider attitudes Direct & indirect costs (public treatment) Perceptions of quality of care public facilities drive people away, even when prices are very low or free.
4. TB – key facts 13,700,000 cases of TB worldwide (2007) 1,770,000 (estimated) TB deaths (2007) The poor & marginalized are the worst affected 95% of cases & 98% of deaths from TB occur in developing & “transition” countries.
5. Where are people dying from TB?
6. Asia has the largest TB burden country rankings Viet Nam Kenya Brazil United Republic of Tanzania Uganda Zimbabwe Thailand Mozambique Myanmar Cambodia Afghanistan India China Indonesia Nigeria South Africa Bangladesh Ethiopia Pakistan Philippines Democratic Republic of Congo Russian Federation
7. TB...a public health program missing many sick people Program success requires: Catching 70% or more of people sick with TB Doing accurate diagnosis Treating properly at least 85% of these people What is being achieved: of the people control program are reaching, 82% of them are getting correct treatment with DOTs BUT, globally less than half the people with TB are reached by programs. Progress in TB control has stagnated. Guess why.
8. Site of Treatment– South Southeast Asia
9. TB patients going private No direct data, but several pointers: Health services utilization by TB patients Retail sale of TB drugs Size of the growing private sector Health care expenditure in private sector Low case notification despite program “coverage”
10. TB case load in the private sector, 2000 Country Retail Sales Cost / Course Estimated (USD Million) (USD) Cases India 85.3 100 853000 Indonesia 12.3 100 123000 Pakistan 11.7 100 117000 Philippines 16.6 200 83000 Bangladesh 2.3 100 23000
11. What is the problem with people “going private”? India: 75% to 88% of TB patients' first contact was a private provider How private practitioners treat TB patients Year Doctors Regimens 1991 100 80 1994 113 90 1996 105 79
12. They diagnose badly Tests Patients Urban (%) Rural (%) Sputum alone 0 0 X-ray alone 56 78 X-ray + Sputum 21 10 Information unavailable 23 12
13. They often manage TB badly Practice Desirable Actual DiagnosisSputum basedX-ray based TreatmentFixed regimensVaried regimens MonitoringDOT No DOT Sputum examX-ray EvaluationCure rate None
14. Private practitioner engagement strategies Many question whether private practitioners can be motivated to change behaviour in necessary ways
15. Key fact: Target private providers are highly fragmented and dispersed Key finding: Intermediary actors critical (e.g. NGO hospital; Damien Foundation, medical association, existing PHC franchise)
16. What makes the instruments work? Direct financial incentives not essential Free drugs (in-kind incentives) Quality focus (practitioners care!) Providing access to training & equipment Professional recognition
17. Information dissemination is key!
18. Information dissemination (demand creation) is key Participating practitioners attract more patients..... Information campaigns Branding Leaflets etc
19. Private practitioners CAN treat appropriately..... even informal practitioners(New sputum positive cases) Informal practitioners! Global target: 85% success Free drugs Not free drugs
20. Private sector engagement significantly increases case detection Average increase 30%
21. Source: Katherine Floyd, STB Private practitioners can even treawt more cost effectively than public
22. Critical Success Factors Building capacity of control program locally & nationally is critical National policy / guidelines Regular drug supply Supervision capacity Public-private stakeholder dialogue is critical
23. Critical Success Factors Sensitising public sector staff Pragmatism & “evidence-based advocacy” Private sector engagement “network” – supported by STOP TB/ WHO
24. Private sector engagement and TB MDGs "by 2015, to have halted and begun to reverse the incidence of malaria and other major diseases" Potential contribution of private sector engagement: Improve treatment success Increase case-detection under DOTS Reduce diagnostic delay
25. Huge opportunity for private sector to contribute to TB control....but....mostly missed Many control programs still implemented only through public sector; Others, at quite small scale
26. Many pilots in India, but no scale up Total expenditure is $70M per year. The amount spent last year working with the private practitioners is $588k. That is, less than 1% of overall program expenditure.
27. Insights from TB private sector engagement initiative so far? Just because it works, and you have evidence, doesn’t mean it will be scaled up and applied in other countries. The power of? Inertia? Ideology?
28. TB and Course Framework Experience shows usefulness of framework in moving from problem identification, to strategy development & implementation. In implementation we learned that key actors are not just private sector but also representative bodies and mid-level policymakers and program managers.
29. TB Insights Private sector engagement strategy was identified and instruments successfully used to harness a range of private actors – suited to program specifics and local context. Lack of expansion illustrates the significant barriers to private sector engagement....even when program success is impossible without it.
30. Framework applied to TB Strategies Harness private practitioners Grow quality lab services Policy Tools Contracting Training/Info Social franchising Public Sector Actors Private practitioners Village health workersDiagnostic labs Ownership For-profit small business Non-profit charitable Formal and informal Goal Control TB Reach TB patients Proper diagnosis Effective treatment Assessment Stagnant coverage of TB control programs Private sector treats most TB patients Private Sector Source: Harding & Preker, Private Participation in Health Services, 2003.
31. Key Sources “Pragmatist-in-chief” MukundUplekar, Head of the STOP TB/ WHO initiative to engage the private sector in TB control. Uplekar, M and A Harding, Chapter 4, in “Private Patients: Why health aid fails to reach so many, and what we can do about it” by A. Harding, forthcoming from Brookings/ Center for Global Development Press, Washington DC.
32. Teaching objectives To see the course framework in application to a program & specific goal (e.g. reduction of TB morbidity & deaths) To explore the linkage between private sector omission and program performance To understand the policy instruments used to engage the private sector for TB control To understand how engagement happened in a very public-sector focused global program